I am just starting to figure out how to do audits on our e/m coding and i have a question. If a pt is coming in for follow up to a cardiac cath with stent and his having no problems and the dr. documents subjective findings and using those same findings in the ros how do i figure out the correct e/m code? He did not do any PFSH either. i really need help with this. When the patient's are coming in for routine follow with no c/o i get very confused. the other thing is if dr. says pt denies chest pain, shortness of breath, nausea, vomiting, orthopnes under subjective then says the same under ros what can i give credit for? I am a little lost. If someone could help me i would appreciate it. shelly